Spotlight on Cardiothoracic Anesthesia
Spotlight on Cardiothoracic Anesthesia by Lisa Lewis, MS
Nearly every day, a cardiac surgery at UCLA changes course based on the recommendations of a cardiothoracic anesthesiologist in the Department of Anesthesiology & Perioperative Medicine (DAPM).
“In my experience, that’s a little bit unique in the world of anesthesiology,” said Reed Harvey, MD, Program Director, Cardiothoracic Anesthesiology Fellowship.
“At the time of surgery,” he explained, “we’re using echocardiography and ultrasound and discovering more about the patient’s heart. We often influence the direction of the surgery and are able to help guide the surgeons toward doing the best and most appropriate procedure for that patient.”
The process is “intensely collaborative,” said Jason Batten, MD, MA, who joined the department faculty last month after concluding dual UCLA fellowships in Cardiothoracic Anesthesiology and Anesthesiology Critical Care Medicine. “I think this collaboration changes the relationship with the surgical team substantially.”
Collaboration and complex cases
A common scenario is mitral valve repair, which requires high-level diagnostic imaging both immediately prior to and during the actual procedure. Using the first set of images, the anesthesiologist makes guided recommendations to the surgeon about specific areas of the valve.
Then, during the surgery, “we evaluate in real time to assess the efficacy of the repair,” said Dr. Harvey. “The surgeon is just finishing up the repair and we’re coming off of cardiopulmonary bypass, and the anesthesiologist is helping make these kinds of split-second decisions about how the repair has gone and whether it’s good to go or whether we need to go back in.”
Another procedure that is become increasingly common at UCLA for patients with atrial fibrillation requires real-time echocardiography guidance to position the WATCHMAN implant device in the left atrial appendage.
“Everyone’s left atrial appendage is unique, and the anatomy of that specific patient is very important to know for the sizing of the device and the angle for approach,” Dr. Harvey explained. “It’s a great example of real-time collaboration: the procedure is done by the cardiologist, but with our continuous imaging guiding every step of the way.”
Over the last five to six years, the WATCHMAN procedure has become increasingly common at UCLA, Dr. Harvey said. “It used to be one day a month, and now it seems like multiple days every week.”
Transplant cases, especially for high-risk patients, have also increased, he noted. “A lot of them are repeat transplants or critically ill patients on extracorporeal membrane oxygenation (ECMO), and we also do a number of heart transplants in patients with congenital heart disease.”
Collaboration is also a hallmark of a cardiac pain management initiative that Tiffany Williams, MD, PhD, helped bring to UCLA. She worked with colleagues in Acute Pain and Regional Anesthesiology, Cardiothoracic Anesthesiology, and Cardiothoracic Surgery on the new approach—Regional Anesthesia for Cardiothoracic Enhanced Recovery (RACER).
“Historically, some of the techniques we use for pain management that could work in cardiac surgical patients were avoided because they had a risk-benefit profile that was weighted heavily to risk,” Dr. Williams explained. She cited epidurals as an example, given the attendant risk of epidural hematomas.
Now, however, there are different types of blocks that have a lower risk profile. “We’ve rolled out RACER in specific cases and specific surgeries, mostly for minimally invasive, robotic mitral valve surgeries,” she said. “And what we’ve seen is that it’s been very effective.”
Patients are now able to be extubated in the OR and have better pain control, Dr. Williams said. They are also able to move out of the ICU more quickly and be discharged home sooner.
The new blocks are also now being used in the cardiac catheterization lab for some pacemaker placements, she said.
Providing facility-wide support
The department’s cardiothoracic anesthesiologists provide perioperative and interventional echocardiography wherever it is needed throughout Ronald Reagan UCLA Medical Center.
“Every single day, we have one cardiac anesthesiologist and one of the fellows assigned to provide cardiovascular imaging support all over the hospital: in the ICU, in the cath lab, in Interventional Radiology, in operating rooms, in the pre-op area, and in the PACU area,” Dr. Harvey said. “The service honestly doesn’t exist anywhere else. We have a dedicated team that’s not in an operating room doing ultrasounds and echoes all in support of all kinds of other surgeries and anesthesiologists in our department.”
Another frequent service involves temporarily reprogramming patients’ pacemakers or defibrillators in preparation for surgery, then restoring them to baseline settings afterwards. “The electrical cautery the surgeons use can interfere with the functioning of the devices,” Matthew Fischer, MD, MS, explained.
Collaborating across and within the department is a core mission of the cardiac division. This may be for acute intraoperative management of a newly unstable patient, strategizing for the care of a patient with cardiopulmonary disease coming for non-cardiac surgery, or perioperative cardiac device optimization. “If our colleagues need cardiac support or have questions or just want someone else in the room,” Dr. Batten said, “we’re delighted to be supportive.”
A strong focus on research
In addition to their clinical responsibilities, many of the division’s faculty members are engaged in research that has implications not just for cardiothoracic anesthesiology, but for anesthesiology and for overall patient outcomes at large.
Up to 40% of patients develop post-operative atrial fibrillation after cardiac surgery, which can lead to morbidity and mortality. Dr. Fischer, a veteran in the cardiac surgical division, is investigating this. “It’s my thought that the surgery is like a stress test that reveals an underlying predisposition to atrial fibrillation,” he said.
To help test this theory, he designed a study that analyzed tissue samples from mitral valve surgery patients. “In this cohort, the incidence is usually about 50% or so,” he said. While this postoperative arrhythmia may be transient, it’s “kind of a tell of what may be developing later on.”
These patients may develop atrial fibrillation years later, Dr. Fischer explained: “It’s this progression that’s been occurring all along in their heart, and now it’s reached the threshold where they may have a-fib outside of the surgical realm.”
Dr. Fischer worked with a team of researchers within the department, including Adrian Arrieta, PhD, Marina Angelini, PhD, Douglas Chapski, PhD, Riccardo Olcese, PhD, and Thomas Vondriska, PhD, as well as Richard Shemin, MD, Chair of Cardiothoracic Surgery, who provided the tissue samples.
They found that people who developed atrial fibrillation had lower levels of FGF13, a protein that helps the function of sodium channels in cardiac myocytes, or muscle cells. The research group replicated the condition in rats and found that electrical activity was significantly different.
The study was published last year in the Journal of the American Heart Association. Dr. Fischer is currently working on developing new drugs to target this pathway, although he noted that applicability for humans is still years away.
Meanwhile, by harnessing the large datasets that are inherent to every cardiac surgical case because of patient monitoring, Dr. Williams is applying her expertise in computation to improve care for surgical patients.
“From my perspective, there’s a lot of low-hanging fruit in the perioperative space where we can use AI techniques to make our lives as anesthesiologists easier, improve the patient experience, improve efficiency, and make sure we can safely get cases done and take care of our patients,” she said.
AI requires data, she noted, and cardiac surgery and congenital heart disease are areas that are data-rich. “Many of these patients have frequent interactions with the health care system, she added, “so not only do you have a lot of information, but you have temporal information.”
Dr. Williams is currently working on several projects focusing on using waveform (temporal) data and vital data to predict negative postoperative outcomes in congenital heart disease patients who undergo non-cardiac surgeries. She uses data from the preoperative, intraoperative, and immediate postoperative phases to predict significant clinical outcomes such as acute kidney injury or respiratory failure.
Another current project involves using natural language and processing to review clinical notes, identify congenital heart disease patients, and categorize them using evidence-based risk-stratification systems.
In addition to working with the department’s Division of Bioinformatics & Perioperative Analytics and the Cannesson Laboratory, she works with other researchers throughout UCLA.
Dr. Batten, whose research interests center on the ethics of life-sustaining treatments, especially mechanical circulatory support, for perioperative and critically ill patients, describes the cardiothoracic anesthesiology division as a “research powerhouse.” He added, “I’m super grateful to have academic research-minded colleagues who can help me understand how to integrate such a high-intensity clinical practice with a thriving research life.”
Professional-society leadership
For many of the department’s cardiothoracic anesthesiologists, that focus on research includes leadership in the Society of Cardiovascular Anesthesiologists (SCA).
“Our group has a pretty robust connection with SCA,” said Jonathan Ho, MD, Director of UCLA Interventional Cardiovascular Operations. “It infuses a lot of what we do on the educational side, on the research side, and on the clinical side.”
In April 2025, Dr. Ho chaired the SCA Annual Meeting in Montreal, at which 17 DAPM faculty members and trainees, including Dr. Ho, presented or moderated various sessions or posters. Highlights included multiple presentations by J. Prince Neelankavil, MD, Chief of the Division of Cardiothoracic Anesthesiology, as well as “Best of Meeting” presentations by Dr. Batten and Inkyung Song, MD, PhD.
For Laura Lowe, MD, an anesthesiology resident who will begin her Adult Cardiothoracic Anesthesiology Fellowship next year, being able to present at the meeting under the mentorship of Dr. Batten and Louis Saddic, MD, PhD, was a joy. “I think I was the only resident of our class going into cardiac anesthesiology who got to do that,” she said.
Many of the division’s cardiovascular anesthesiologists serve in various SCA committee leadership roles, said Dr. Ho, who will also chair next year’s annual meeting in April 2026 in Nashville. That list includes Dr. Fischer, who received his first research grant from SCA and is now on the Research Committee, which provides grants as well as guidance for researchers in the field.
Others in leadership roles include Ashley Oliver, MD, MA, who is currently in the first year of a two-year term on the SCA’s Scientific Program Committee, led by Dr. Ho. Dr. Oliver served for five years on the Health Equity and Professional Advancement Committee and was a 2023 recipient of the Kaplan Award for Leadership Development. Serving on this committee is “a great opportunity to serve the society that has helped me launch my career,” she said.
Women in cardiothoracic anesthesiology
In 2018, Emily Methangkool, MD, MPH, Chair of the Department of Anesthesiology at Olive View-UCLA Medical Center, was a founding member of Women in Cardiothoracic Anesthesia, an SCA special interest group, after noting the lack of visibility and leadership of women in the subspecialty. Over the past seven years, the group has focused on professional development to help close the gap and to increase representation for women.
“Interestingly, women probably make up about 30 to 33% of anesthesia graduates, but only about 25% of cardiac anesthesia attendings,” she said. “We were also seeing on the national stage – in speakerships and committee leaderships and those kind of roles – that women weren’t very visible.”
Dr. Methangkool and the other group members created mentoring programs and also did a needs assessment, in addition to creating other forms of outreach.
“I think it’s been very successful in increasing the visibility of women within the field and within the society,” she said.
Dr. Methangkool, who became the chair at Olive View in 2023, noted that within the last ten years, the number of women in the division has increased substantially.
“There have been concerted efforts by Dr. Neelankavil and Dr. Ho,” she noted. “When I first started, there were maybe three women in the division – now it’s close to 50%.”
Dr. Methangkool sees the adoption of flexible work schedules as a key strategy going forward, both to address the number of women in the specialty and to address workforce shortages. “Cardiac anesthesia is a little more of a grueling schedule,” she said. “There’s increasing recognition at a societal level and at a leadership level that these schedules are the way of the future.”
Providing care beyond UCLA
In addition to the ongoing work done under the auspices of SCA, several members of the division are involved in broader efforts to share expertise with colleagues elsewhere in the United States and globally, including Dr. Williams and Maziar Nourian, MD.
For Dr. Williams, one area of interest is combined heart-liver transplants. “These are done primarily in patients who have a failing Fontan palliation, and patients who have single ventricle anatomy,” she said. “These are surgically complex patients, very high risk and very resource intensive, with lots of team coordination.” Given that UCLA is one of the centers in the country that does a fair number of these transplants, she focuses on sharing that expertise with others. “I want to educate our broader community about what it takes to do these,” she said, “and what it takes to be successful.”
Dr. Williams embarks on several global trips each year to support local health teams develop cardiac-related expertise in pediatric cardiac surgery and electrophysiology procedures. She was in Honduras over the summer and will be traveling to Jordan early next year.
A unique environment: dynamic, yet supportive
“Cardiac ORs are often a pretty high-stress place, with very sick patients and cases going long into the night,” Dr. Harvey said. “I think we all really find a lot of value in taking care of these patients. We have an incredibly supportive group: everybody’s constantly looking out for each other, and knowing who’s been up late at night or who’s had some tough patient outcomes. Being a small group with Dr. Neelankavil’s leadership, we’re supporting each other in a professional growth standpoint as well.”
Dr. Oliver noted that as in many subspecialties, developing relationships is core to the sense of fulfillment that these cases can provide. “There are almost infinite possibilities for interpersonal connection and developing relationships: with the nurses and scrub techs in the OR, with the surgeons as well as the perfusionists and the intensivists, and with the patients and their families being at the center.”
There is a stereotype that every cardiac case is the same, said Dr. Batten. “There can be an element of routine when the case is going well. But as everybody at Reagan knows, our patients are complex and sick, and so it gets really wild sometimes.”